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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 29 )

Updated On: 12-Jan-2026
Page 29 of 345
PDF with 862 Questions

A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:

  1. Insist that she remain at the table and eat a balanced diet.
  2. Order a high-calorie diet with supplements.
  3. Provide nutritious finger foods several times a day.
  4. Offer to go to the dining room with her and allow her to open the food and inspect what she eats.

Answer(s): C

Explanation:

(A) The client is not able to sit for long periods. Forcing her to remain at the table will increase her anxiety and cause her to become hostile. (B) This action will not ensure that the client eats what is ordered. Dietary orders are not within the nurse's scope of practice. (C) Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating "on the run." (D) These clients are not suspicious of the food or insecure in moving about the unit alone.



The physician prescribes phenytoin (Dilantin) for a client with seizure disorders. Phenytoin can only be mixed with which of the following solutions?

  1. Ringer's lactate
  2. D5 in water
  3. D5 with Ringer's lactate
  4. Normal saline

Answer(s): D

Explanation:

(A) Phenytoin will precipitate if mixed with Ringer's lactate and should not be administered. (B, C) Phenytoin will precipitate if mixed with D5 in Ringer's lactate and should not be administered. (D) Phenytoin is compatible only with normal saline and should be mixed only with normal saline for administration.



Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders?

  1. Heterozygotes are affected.
  2. The disorder is always carried on the X chromosome.
  3. Only females are affected.
  4. Two affected parents always have affected children.

Answer(s): D

Explanation:

(A) The term heterozygote refers to an individual with one normal and one mutant allele at a given locus on a pair of homologous chromosomes. An individual who is heterozygous for the abnormal gene does not manifest obvious symptoms. (B) Disorders carried on either the X or Y sex chromosome are referred to as sex-linked recessive. (C) Either sex may be affected by autosomal recessive genetic disorders because the responsible allele can be on any one of the 46 chromosomes. (D) If both parents are affected by the disorder and are not just carriers, then all their children would manifest the same disorder.



A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will "beat out of her chest." The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:

  1. Starting an 18-gauge IV infusion
  2. Having the consent form on the chart
  3. Administering the correct blood product to the correctclient
  4. Transfusing the blood in a 2-hour time frame

Answer(s): C

Explanation:

(A) An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. (B) The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. (C) Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. (D) The blood administration should take place over the ordered time frame designated by the physician.



The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:

  1. Careful monitoring of weight loss or gain
  2. Carefully recording amounts and types of foods ingested
  3. Keeping a strict account of the number of calories ingested
  4. Keeping a careful account of the amount of pancreatic enzymes ingested

Answer(s): A

Explanation:

(A) Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories. (B) Recording how much the child eats is useful, but it is not an indicator of how well his body is using the foods consumed. (C) Counting calories will indicate how much he is eating, but it will not reflect whether or not the foods are properly digested. (D) Keeping track of the enzyme intake will indicate compliance with medication but not whether the child is getting sufficient calories.



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